The Movement is not just about information, it is about action! By addressing new challenges and forming Actionable Patient Safety Solutions (APSS) the PSMF believes we can reduce the number of preventable deaths in hospitals to ZERO by 2020.
Below you will find links to solutions to overcome some of the leading patient safety challenges facing hospitals today.

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Executive Summary Checklist

In order to establish a program to improve hand hygiene and reduce healthcare-associated infections (HAIs), the following implementation plan will require actionable steps. The following checklist was adapted from the WHO Hand Hygiene Self-Assessment Framework \cite{world2013hand}.

Commitment from Hospital governance and senior administrative leadership to address this major performance gap in their own organization by taking action.

Mandate a hand hygiene protocol that is supported by hospital leadership

Immediate feedback to healthcare workers at the end of each hand hygiene compliance observation session.

Systematic feedback of data related to hand hygiene indicators and trends given monthly, as well as every 6 months.

Reminders in the workplace such as posters, brochures, leaflets, badges, stickers, etc.

The Performance Gap

Hand hygiene contributes significantly to keeping patients safe. While hand hygiene is not the only measure to counter HAI, compliance with it alone can dramatically enhance patient safety, because there is much scientific evidence showing that microbes causing HAI are most frequently spread between patients on the hands of health- care workers. Many patients may carry microbes without any obvious signs or symptoms of an infection (colonized or sub clinically-infected). Microbes have an impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned. This clearly reinforces the need for hand hygiene, irrespective of the type of patient being cared for .

Health-care facilities which readily embrace strategies for improving hand hygiene also prove more open to a closer scrutiny of their infection control practices in general. Therefore, the impact of focusing on hand hygiene can lead to an overall improvement in patient safety across an entire organization. The hands of staff can become contaminated even after seemingly ‘clean’ procedures such as taking a pulse, blood pressure, or touching a patient’s hand \cite{world2009guidelines}.

Leadership Plan

Hospital governance and senior administrative leadership must commit to becoming aware of this major performance gap in their own organization.

Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach.

Healthcare leadership must reinforce their commitment by taking an active role in championing process improvement, giving their time, attention and focus, removing barriers, and providing necessary resources.

Leadership must demonstrate their commitment and support by shaping a vision of the future, clearly defining goals, supporting staff as they work through improvement initiatives, measuring results, allocating resources, and communicating progress towards goals. Actions speak louder than words. As role models, leadership must ‘walk the walk’ as well as ‘talk the talk’ when it comes to supporting process improvement across an organization.

There are many types of leaders within a healthcare organization and in order for process improvement to truly be successful, leadership commitment and action are required at all levels. The Board, the C-Suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.

Practice Plan

Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increase the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs.

Plan the Project:

Build a strong foundation for change by assessing the culture for change, defining the change, building a strategy, engaging the right people, and painting a vision of the future. This should be done at the outset of the project.

Inspire People:

Solicit support and active involvement in the plan to reduce HAIs, obtain buy-in and build accountability for the outcomes.

Identify a leader for the HAI initiative. This is critical to the success of the project.

Understand where resistance may come from.

Launch the Initiative:

Align operations and ensure the organization has the capacity to change, not just the ability to change.

Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.

Support the Change:

The capacity to support change is critical; therefore, all leaders within the organization must be a visible part of the HAI initiative.

Frequent communication regarding all aspects of the HAI initiative will enhance the initiative.

Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.

Identify resistance to the HAI initiative as soon as it occurs.

Hand hygiene improvement is not amenable to a “one size fits all” approach. It involves a complex set of interactions that requires an approach focused on measurement and understanding of root causes. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® provides health care organizations this type of comprehensive approach and is proven to improve hand hygiene compliance \cite{joint2012joint}.

Define hand hygiene protocol

Who to follow hand hygiene:

All personnel and visitors in contact with or in the proximity of patients, including the patient.

Hand wash with soap and water or hand rub over all hand surfaces with alcohol-based formulation.

Hand rub/hand wash for at least 15 seconds.

Dry hands completely.

Do not touch potentially contaminated surfaces after hand washing procedure.

Educate all staff on hand hygiene procedure and implications of non-compliance.

Train observers and just in time (JIT) coaches.

Measure current “baseline” adherence to hand hygiene protocol with observers who sample and record compliance within the hospital units.

Observers should be a role or individual that can maintain anonymity throughout the data collection process, be in a position where they can secretly observe staff while performing their regular job duties, not seem out of place during their time on the unit, and collect data that is representative of the patient population.

Twenty to thirty observations should be collected each day over a two to three-week period utilizing a standardized data collection form including observation number, date and time, staff role, entry or exit to patient room, hand hygiene - yes or no, observable contributing factor to non-compliance.

Identify barriers to hand washing.

Qualitative input from secret observers as to observable contributing factors as to why hand hygiene protocol was not followed.

Direct interviews with noncompliant caregivers by just-in-time (JIT) coaches within the hospital units to identify non-observable factors as to why hand hygiene protocol was not followed.

Collect data on barriers to hand washing and calculate the hospital (or unit) baseline compliance, top contributing factors to non-compliance at your hospital (or unit), and the compliance by role(s).

Analyze the data to identify root causes of why non-compliance is occurring.

The top causes (or contributing factors) vary across units and hospitals, roles and shifts. Thus, it is crucial that data is first collected and analyzed to identify the factors which contribute to hand hygiene non-compliance in your area. In order to improve hand hygiene, it is essential that solutions targeting the specific causes are implemented.

Not all causes are applicable to your organization and often there are two or three major causes that need to be addressed.

For instance, if the unit identifies that “improper use of gloves” is the top contributing cause of hand hygiene non-compliance, then the following targeted solutions can be implemented:

Detailed training for clinical staff on proper use of gloves.

Relocate glove dispensers.

Implement standard work process for hand washing between each patient room or patient care area when delivering food trays.

Implement standard work process for daily room cleaning and educate all housekeeping personnel.

Another example of a contributing cause could be “frequent entry or exit.” If the unit finds that this is a top contributing cause through the use of the TST, then the following solutions can be implemented to improve hand hygiene:

Implement standard work process for hand washing after bringing mobile work machines (such as mobile vital signs devices) into the patient room or care area but before patient contact/interaction (such as taking patient’s vital signs).

Create a standard “drop spot” for meds and supplies within the patient room that enables nursing to set down meds and supplies and perform hand washing.

Implement computers and scanners at every bedside to reduce the likelihood of cross-contamination between patients when performing bar code medication administration.

Implement standard work process for room cleaning and educate all housekeeping staff.

Create and implement a list of supplies that will be kept within the patient care area.

Measure progress and effectiveness of change.

Utilize the same data collection and analysis tools and process utilized to calculate baseline in order to measure progress and effectiveness.

Identify the changes from baseline performance for each unit, role, and shift, and identify the effectiveness of implemented solution, any barriers to effectiveness, and any additional solutions that need to be implemented.

Note: The TST includes data collection forms and provides analyses in the form of Pareto (and other) charts that allows your organization to track improvement versus baseline data, to observe HAI data in correlation to hand hygiene compliance rates, and to benchmark against national results.

Implement a plan to ensure that gains are sustainable.

The plan should include the following action items:

Designate someone to “own” the process (for example, the dedicated leader or a unit manager). At least one aspect of their job function should specify that data continue to be collected, monitored and shared with healthcare personnel.

Replicate the findings to another area within your organization.

Continue real time data collection to improve data collection.

Train new hand hygiene observers and JIT coaches, once per year to ensure that observers receive updated training on an annual basis.

Update the plan whenever changes occur.

The plan should be completed with the process owner, which signals the transition of responsibility from the project leader.

The project leader will continue to ensure that data is collected, entered and shared with staff at a frequency determined by the group.

Technology Plan

The recommendations of specific technologies or products herein are those of the Patient Safety Movement Foundation and do not necessarily represent the opinions of the Joint Commission Center for Transforming Healthcare or its affiliates. The Joint Commission Center for Transforming Healthcare was not consulted on, nor did it participate in the decision or choice of any specific product or technology, and as a matter of policy the Joint Commission Center for Transforming Healthcare does not endorse any specific technologies, equipment, or other products.

There is emerging evidence that electronic hand hygiene compliance systems, when combined with appropriate staff feedback and multi modal action plans can lead to reduced infections and avoided costs. Visit http://www.ehcohealth.org/the-evidence/ for a list of scientific studies.

Essential Criteria to Consider

The system must be:

Capable of capturing 100% of all hand hygiene events (soap and sanitizer) electronically in real-time.

Capable of reporting Hand Hygiene Compliance (HHC) based on the WHO 5 Moments for Hand Hygiene at the Group, Unit, Ward or Department Level.\cite{Steed_2011}

Validated for accuracy in at least one peer reviewed study.\cite{Diller_2014}

Supported by scientific evidence of efficacy.

Supported with a behavior and culture change tool kit.

Consider an Electronic Monitoring System for Hand Hygiene Compliance to ensure an accurate and reliable data set from which real improvement can be driven, such as:

Metric Recommendations

Data Collection: Direct observation of hand hygiene practices in identified clinical settings with one (or two) trained and validated observers. Observers will watch healthcare workers’ hand hygiene practices at the point-of-care. The observer openly conducts observations but the identities of the healthcare workers are confidential. Based on WHO Guidelines on Hand Hygiene in Healthcare (2009) and “Save lives, Clean Your Hands” campaign. (World Health Organization 2009)

Appendix A

“Facilitating Change,” the change management model The Joint Commission developed, contains four key elements
to consider when working through a change initiative to address HAIs..

Plan the Project:

● Build a strong foundation for change by assessing the culture for change, defining the change, building a
strategy, engaging the right people, and painting a vision of the future. This should be done at the outset of
the project.

Inspire People:

● Solicit support and active involvement in the plan to reduce HAIs, obtain buy-in and build accountability
for the outcomes.

● Identify a leader for the HAI initiative. This is critical to the success of the project.

● Understand where resistance may come from.

Launch the Initiative:

● Align operations and ensure the organization has the capacity to change, not just the ability to change.

● Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.

Support the Change:

● The capacity to support change is critical; therefore, all leaders within the organization must be a visible
part of the HAI initiative.

● Frequent communication regarding all aspects of the HAI initiative will enhance the initiative.

● Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.

● Identify resistance to the HAI initiative as soon as it occurs.

Appendix B

The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® helps organizations
accurately measure their actual performance, identify their barriers to excellent performance, and direct them to
proven solutions that are customized to address their particular barriers related to hand hygiene.

The TST includes the following steps:

Define hand hygiene protocol

Who to follow hand hygiene:

All personnel and visitors in contact with or in the proximity of patients, including the
patient.

Hand wash with soap and water or hand rub over all hand surfaces with alcohol-based
formulation.

Hand rub/hand wash for at least 15 seconds.

Dry hands completely.

Do not touch potentially contaminated surfaces after hand washing procedure.

Educate all staff on hand hygiene procedure and implications of non-compliance.

Train observers and just in time (JIT) coaches.

Measure current “baseline” adherence to hand hygiene protocol with observers who sample and record
compliance within the hospital units.

Observers should be a role or individual that can maintain anonymity throughout the data
collection process, be in a position where they can secretly observe staff while performing their
regular job duties, not seem out of place during their time on the unit, and collect data that is
representative of the patient population.

Twenty to thirty observations should be collected each day over a two to three-week period
utilizing a standardized data collection form including observation number, date and time, staff
role, entry or exit to patient room, hand hygiene - yes or no, observable contributing factor to noncompliance.

Identify barriers to hand washing.

Qualitative input from secret observers as to observable contributing factors as to why hand
hygiene protocol was not followed.

Direct interviews with noncompliant caregivers by just-in-time (JIT) coaches within the hospital
units to identify non-observable factors as to why hand hygiene protocol was not followed.

Collect data on barriers to hand washing and calculate the hospital (or unit) baseline compliance, top
contributing factors to non-compliance at your hospital (or unit), and the compliance by role(s).

Analyze the data to identify root causes of why non-compliance is occurring.

The top causes (or contributing factors) vary across units and hospitals, roles and shifts. Thus, it is
crucial that data is first collected and analyzed to identify the factors which contribute to hand
hygiene non-compliance in your area. In order to improve hand hygiene, it is essential that
solutions targeting the specific causes are implemented.

Not all causes are applicable to your organization and often there are two or three major causes
that need to be addressed.

For instance, if the unit identifies that “improper use of gloves” is the top contributing cause of hand
hygiene non-compliance, then the following targeted solutions can be implemented:

Detailed training for clinical staff on proper use of gloves.

Relocate glove dispensers.

Implement standard work process for hand washing between each patient room or patient care area
when delivering food trays.

Implement standard work process for daily room cleaning and educate all housekeeping personnel.

Another example of a contributing cause could be “frequent entry or exit.” If the unit finds that this is a top
contributing cause through the use of the TST, then the following solutions can be implemented to improve
hand hygiene:

Implement standard work process for hand washing after bringing mobile work machines (such as
mobile vital signs devices) into the patient room or care area but before patient contact/interaction
(such as taking patient’s vital signs).

Create a standard “drop spot” for meds and supplies within the patient room that enables nursing
to set down meds and supplies and perform hand washing.

Implement computers and scanners at every bedside to reduce the likelihood of crosscontamination
between patients when performing bar code medication administration.

Implement standard work process for room cleaning and educate all housekeeping staff.

Create and implement a list of supplies that will be kept within the patient care area.

Measure progress and effectiveness of change.

Utilize the same data collection and analysis tools and process utilized to calculate baseline in
order to measure progress and effectiveness.

Identify the changes from baseline performance for each unit, role, and shift, and identify the
effectiveness of implemented solution, any barriers to effectiveness, and any additional solutions
that need to be implemented.

Note: The TST includes data collection forms and provides analyses in the form of Pareto (and
other) charts that allows your organization to track improvement versus baseline data, to observe
HAI data in correlation to hand hygiene compliance rates, and to benchmark against national
results.

Implement a plan to ensure that gains are sustainable.

The plan should include the following action items:

Designate someone to “own” the process (for example, the dedicated leader or a unit
manager). At least one aspect of their job function should specify that data continue to be
collected, monitored and shared with healthcare personnel.

Replicate the findings to another area within your organization.

Continue real time data collection to improve data collection.

Train new hand hygiene observers and JIT coaches, once per year to ensure that
observers receive updated training on an annual basis.

Update the plan whenever changes occur.

The plan should be completed with the process owner, which signals the transition of
responsibility from the project leader.

The project leader will continue to ensure that data is collected, entered and shared with staff at a
frequency determined by the group.

Executive Summary Checklist\(\)Achieving a culture of safety in a healthcare organization requires transformational change which is owned and led by the top leaders of the organization, including the board, encouraging accountability and transparency. Hospital boards and senior leaders must commit to compensation policies that ensure that safety performance is aligned with executive compensation. It is a key responsibility of healthcare administrators to prepare the workforce to continually enhance their competencies around hazard and risk identification. Organization-wide commitment to worker safety offers personal awareness building and assist all staff to embrace their personal role as safety officer.Transparency regarding the outcomes of care, both within and outside of the organization, facilitates improvement across the continuum of care.Understanding and implementing Just Culture is essential for transitioning from a culture of shame and blame to one of trust and respect. In a just culture, people are not punished for human errors, but are always held accountable for their decisions.Address unexpected outcomes with open disclosure and prompt resolution. If patient harm results from a preventable medical error, adopt the CANDOR (Communication and Optimal Resolution) Approach: apologize as soon as possible, pay for all care related to the preventable harm, seek a just resolution, and provide ongoing support for patients and families. Clinicians (the "second victims" of patient harm events) may require special attention and support \cite{27558861}.Create a standard of care where the clinicians speak with family members and explain what will be changed so this won't happen again and offer family members an opportunity to be involved and witness the change in procedure, etc.Creation of a reliable means to capture and analyze good catches/near-misses is a key to identifying and addressing processes and systems.Both safety culture and patient outcomes require continual assessment: “What is measured gets managed.”Create and maintain five components of a safety culture to achieve a high reliability organizationEstablish trustEstablish accountabilityIdentify unsafe conditionsStrengthen systemsAssess and continuously Improve the safety cultureDevelop a strong infrastructure ensuring:Budgets that allow for an adequate number and quality of patient safety professionalsImplementation and ongoing monitoring of a comprehensive patient safety program that is approved by the Board of Trustees.Creation of an internal working group made up of quality improvement, nursing, risk management, patient safety, patient advocacy and regulatory leaders.Develop a ‘Good Catch’ Program to recognize and reward staff for reporting near misses or system issues.Integration of worker safety and patient safety strategies and resources.Safety Commitment and goal setting must include aspirations that all errors and incidents are preventable and that zero is the most important goal.Safety has to be personalized for behaviors to change or be sustained. Alignment of patient safety and worker safety activities is an important consideration for workers to be engaged and for reliability.Implement an electronic adverse event reporting system that allows for anonymous reporting, tracking, trending and response to aggregate safety data.Thoughtful and memorable internal branding must be implemented to keep safety expectations and aligned behaviors top of mind throughout an organization. The best safety culture plans and priorities mean nothing if not communicated clearly, widely and repeatedly.The Performance GapDespite widespread efforts among healthcare organizations to improve patient safety and healthcare quality, preventable patient deaths still occur. It is estimated that there could be over 200,000 preventable patient deaths per year in U.S. hospitals alone, and up to one-third of patients unintentionally harmed during a hospital stay \cite{James_2013,Classen_2011}. Preventable medical harm ranks as the third leading cause of death in the United States \cite{Makary_2016}. Such events cause unnecessary human suffering and also waste billions of dollars annually.The confluence of continued preventable safety events, growing public vigilance, patient and provider/staff dissatisfaction, and payment systems that penalize poor outcomes serves as leverage to change how hospitals address quality and safety. However, even with this strong motivation and focused effort to improve safety and quality, evidence suggests that the risk of harmful error may be increasing.Respect: The Essential Foundation of Safety Culture

Executive Summary Checklist

Clinicians and Physicians in acute mental health units rely on the environment, medications and care planning to provide treatment to patients and ensure patient safety. Active care planning during acute mental health treatment that is inclusive of the patient and other supports can have a positive effect on reducing harm to patients, staff, and visitors, by increasing resources for amelioration of strong negative emotions. In this project, active and collaborative care planning is operationalized as the combined use of Comfort Plans and Comfort Kits for assessment and intervention, respectively. This will:

Provide low barrier ways for staff and patients to collaborate on care planning.

Promote patients to take more of an active role in identification and management of symptoms.

Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others.

The Performance Gap

Patient safety events in psychiatry are a serious concern; one thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging (Mills et al, 2013). Suicide is not the only metric for patient safety in psychiatry, which has other unique patient safety issues, such as violence and aggression; suicide and self-harm; seclusion and restraint; and absconding and missing patients. Seclusion rates in an acute inpatient psychiatry unit can reach as high as 31%, with the most common indicator of seclusion was risk to others (74%) followed by risk to self (61%) and risk of absconding (55%) (Tunde-Ayinmode et al., 2004). Up to 47% of mental health care providers have experienced violence at work (Nolan, 1999). As such, there is an urgent need to reduce and mitigate unsafe acts within the mental health care system.

Patients who are in acute psychiatric distress are at risk to harm themselves or others. Collaborative care planning is a tool used to help patients recognize when they are reaching levels of acute psychiatric distress. This self recognition translates into preventing patients from reaching a point of crisis where they are at risk to harm themselves or others. Acute inpatient settings often do a good job of utilizing the environment and medications to promote patient recovery. Patients are admitted to a relatively safe, calm environment removed from the complexities of life that may have triggered the acute psychiatric crisis, and patients receive medication trials under close medical supervision to determine the best pharmacological treatment plan. However, a third arm of treatment, collaborative care planning, is often underutilized (Anthony, P. & Crawford, P., 2000).

Collaborative care planning refers to the combined efforts of staff and patients working together to set and achieve health goals, and involves greater patient involvement in the planning, delivery and evaluation of care. Ideally, it leads to better treatment by focusing on improving and maintaining health rather than just dealing with problems as they arise (Victoria State Government, 2012)). Lack of collaborative care planning often manifests as: patients being unaware of their treatment plan; patients feeling helpless; weak therapeutic relationships between patients and staff. This, in turn, may result in poorer outcomes and increased number of patient safety events. Improved clinical outcomes are known to result from collaborative care planning (Craven et al, 2006).

We aim to increase patient safety by promoting collaborative care planning between staff and patients in acute inpatient psychiatric settings. Collaborative care planning can be encouraged through a relatively simple framework utilizing a Two-Step Comfort Toolkit, which will be described below in the “Practice Plan” section. This framework gives tools for staff to work with patients and their supports to build skills for both evaluation and management of emotional distress, which often precede patient safety events.

Leadership Plan

Provide infrastructure. Use the Two-Step Comfort Toolkit to systematically build patient and support skills development in an effective and efficient manner. Collaborative care planning appears to have particularly strong effects in patients with more severe disorders, and even low levels of collaboration can have positive outcomes (Craven et al., 2006). This is particularly important in acute inpatient psychiatry settings, where psychiatric severity tends to be high, and staff often are time and resource constrained (Porter, 1992).

Provide scope. Develop a guide for staff and physicians to determine appropriate family and supports to be involved in care planning.

Provide capacity. Protect time to engage in patient comfort planning.

Provide capability. Educate staff on how to leverage comfort planning, how to engage patients to identify their triggers, and when to seek additional resources.

Provide motivation. Highlight the importance of patient involvement in patient outcomes, empower staff to take action to proactively assess and include patients in their treatment.

Practice Plan

The Two-Step Comfort Toolkit can be completed in as little as two 30-minute sessions. It should ideally be completed as soon as a patient is settled enough to actively and collaboratively engage with the clinician.

Executive Summary Checklist

Reducing preventable deaths requires a multi-disciplinary, multi-specialty collaborative team. In order to implement a program that will optimize anticipation, identification and resuscitation (AIR) of at-risk patients, an implementation plan to complete the following actionable steps should be followed:

A multi-disciplinary institutional group, the Resuscitation Outcomes Steering Committee (ROSC; would consider changing the name ROSC to the AIR program as resuscitation comes after anticipation and identification of the at-risk patient to identify what type of resuscitation is needed), should be designated as primarily responsible for the AIR program.

Early event detection has the greatest impact on outcomes thus the bedside clinicians (afferent arm) education, training, is the first and most important component of reducing failure to rescue.

A formal mechanism for input data (Afferents) should be identified. This should include both external sources of information, such as guidelines and scientific literature, as well as internal (institutional) data.

The institutional AIRSC should have input into the Efferent actions in response to Afferent data and perceived institutional resuscitation needs.

An effective AIR program will engage individual providers and enhance their personal sense of ownership and accountability. Ultimately, this program should become the primary vehicle to reduce preventable deaths and ensure an institutional culture of safety.

Outcome data should be presented to the hospital medical executive board monthly.

An organized approach to data collection and performance improvement should target various etiologies of cardiopulmonary arrest with regard to reducing arrest incidence, increasing arrest survival and improving end-of-life discussions with patients and families.

The Performance Gap

The Institute of Medicine 2001 report on quality in healthcare identified failure to rescue as a key opportunity for improving patient safety, decreasing preventable deaths, and reducing healthcare expenditures \cite{2001}. The recognition that many in-hospital deaths are preventable has resulted in a myriad of patient safety efforts targeting a variety of clinical scenarios and disease states. While some of these have demonstrated promise, hospitals are often overwhelmed with the selection, implementation, and coordination of these efforts. In addition, healthcare professionals are facing an increasing number of required training modules, but with a concerning lack of engagement in each. The segregation or “siloing” of these efforts limits their clinical effectiveness, effectively devolving them into a regulatory requirement driving so-called “compliance innovation” instead of a truly coordinated effort to improve clinical outcomes \cite{Blind}.

The ultimate consequence of failure to rescue is unexpected cardiopulmonary arrest \cite{Schmid_2007}. The primary mechanism for maintaining resuscitation competency remains the American Heart Association life support training courses: Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS)\cite{20956224}. These courses have several limitations, particularly for in-hospital providers \cite{23479672,or6}:

ACLS/BLS curricula are heavily based on out-of-hospital cardiac arrest. However, recent evidence documents important differences between out-of-hospital and in-hospital arrest etiologies.

Treatment algorithms upon which the ACLS/BLS courses are based cannot incorporate the variety of new technologies that offer tremendous potential to improve outcomes. Finally, there is no emphasis on arrest prevention, which is where the most opportunity exists for improving clinical outcomes in the hospital setting.

An institutional AIR program should target preventable deaths for a particular hospital or healthcare organization. Thus, each of the core elements described below (Steering Committee, Afferents, and Efferents) should reflect and be adapted to that institution. In addition, the core elements should be linked together in an institutional closed-loop performance improvement system.

Advanced Resuscitation Training (ART)

Advanced Resuscitation Training (ART) was developed in 2007 at the University of California at San Diego (UCSD) and represents the archetype for an institutional resuscitation program. The ART program represents a comprehensive system of care that targets the reduction of preventable deaths in both the out-of-hospital and in-hospital environments.6 The ART model links scientific evidence, continuous quality improvement (CQI) data, technology, institutional treatment algorithms, and training (Figure 1). Ownership and accountability are transferred to the institution, enhancing both relevance and engagement.

Executive Summary ChecklistSurvey and assess stakeholder support for those who are in need of a psychiatric bed registry.Increase and secure “buy in” with key players by continued education of need.Implement a real-time electronic bed tracking system.Communicate with key stakeholders who would be using the system.Ongoing monitoring to maintain system in order to adhere to current standards and protocols.Share data for times bed system is full and total bed need is not able to be met.The Performance Gap Between 1970 and 2000, the number of public psychiatric hospital beds dropped from 207 beds per 100,000 people to just 21, according to the federal Agency for Healthcare Research and Quality (AHRQ). A 2010 survey of 603 hospital emergency department administrators by the Schumacher Group, an emergency-room consultancy, found that 56 percent of emergency departments are “often unable” to transfer behavioral patients to inpatient facilities in a timely manner. More than 70 percent of administrators reported wait times of at least 24 hours, and 10 percent had boarded patients for a week or longer. In a 2008 survey of 328 US-based Emergency Department (ED) Medical Directors, 79.2% report routine psychiatric patient boarding with 35.1% boarding greater than 1 patient per day and 38.9% boarding for between 8-24 hours. The survey cited lack of an accepting transferring facility (19.9%), and the inability to transfer to an accepting facility due to bed availability (19.5%), as the most common reasons for extended ED length of stay. Wait time for psychiatric beds in the Emergency Departments are even longer for pediatric patients in comparison to adults. Wait time is even greater for children 12 and younger as even fewer psychiatric beds exist for these children.Between 1995 and 2012, California saw inpatient psychiatric beds drop from 9,300 to 6,500. The fallout within communities by way of increased violence to self and others is undeniable. In 2014, the state of Virginia passed the “Acute Psychiatric Bed Registry" Code (37.2-308.1) as a result of a tragic death of the son of State Senator Creigh Deeds who killed himself after stabbing his father. The state of California has no mandatory psychiatric bed registry and locating psychiatric beds for those in crisis is a challenge. Therefore, a bed registry would allow facilities to locate vacant beds in a more efficient manner to improve quality of care and reduce otherwise avoidable death and suffering. By sharing information and utilizing real-time update systems, professionals are able to determine and locate appropriate facilities with bed availability and resources for the patient.Currently, a great majority of the United States lack an organized system for locating and securing necessary inpatient hospital psychiatric services. The current system is inefficient, cumbersome and wasteful. This is compounded by the increased lack of inpatient psychiatric beds locally and nationally, causing an unreasonable and unnecessarily long wait time for critical patients in outpatient facilities, emergency departments, and other settings before they are able to be admitted to the safety of an inpatient setting. The results include:Delays in initiation of necessary treatment,Injury to staff by acutely ill and agitated patients being boarded in a setting not designed for psychiatric treatment (ie: emergency department),Reduced availability of ED beds for acutely ill medical patients,Unnecessary financial burden and loss for hospitals, Unnecessary and often times unmanageable stress for patients, which only leads to an exacerbation of further symptomsMisuse of hospital staffDue to the vast majority of states lacking a psychiatric bed registry (Figure 1), the task of finding an open psychiatric bed is left up to various hospitals and practitioners. Currently, individuals must resort to repetitive and time consuming phone calls between facilities to locate a possible placement for a patient in crisis. Due to this practice, locating an appropriate bed is often ta result of "luck and timing." It is not uncommon to find multiple facilities placing calls at the same time in search for a bed. As a result, costs accumulate, the patient and family experience long wait times while they languish in emergency departments, on medical floors, and in psychiatric boarding rooms.A facility that is unable to locate an appropriate bed for the psychiatric patient is left to absorb the numerous financial costs, including but not limited to, extra staffing costs to supervise the patient, loss of revenue for that occupied bed, possible departmental diversion costs, etc. All of these factors contribute to an overall increase in healthcare costs.

Executive Summary Checklist

Failures of airway management (e.g., inability to mask ventilate or oxygenate, unplanned extubation, failure to intubate) are major causes of inpatient morbidity and mortality. The following steps will establish an institutional, team-based, comprehensive and sustainable system for reliability in airway management.

Establish the need for improvement by examining current vulnerabilities, using known and simulated complications and difficult cases, along with key statistics.

Create the vision of institution-wide reliability for airway management safety through standardization of best practices, policies and procedures.

Under the leadership of a physician anesthesiologist, develop a comprehensive airway toolkit method (e.g., the Safer Airway Bundle) \cite{airway1}. Start implementation in the ED and ICUs, and then move to floor units and other departments. Include the following Key Components: Failed Airway Path, Airway Cart, Airway Checklist, Quality Assurance, and Team Training.

Require tracking and reporting of “near misses” and complications of airway management. Identify adverse outcomes that are iatrogenic and preventable (eg. multiple attempts, esophageal intubation, SpO2 <90% or decline of >10%, dental or soft tissue injury). Use these case data in medical staff educational sessions to prevent recurrences, as a part of Continuous Quality Improvement (CQI).

Provide periodic airway management education for all care providers. This will include: identification of airway problems, selection and use of appropriate intervention, and understanding when and how to call for expert assistance (e.g. from Anesthesiology).

Centers for Medicare and Medicaid Services (CMS) has identified Airway Safety as a priority area for Round 2 of the Hospital Engagement Networks (HENs) due to the high risk and significant impact of airway related injuries and deaths. Several United States and European organizations have provided focused evidence based clinical recommendations to their specialty membership and general audiences. There have been few calls for specific standards outside of the operating room (OR). We strongly promote that this needs to change.

This Airway Safety APSS serves to highlight key need areas for best practice development and implementation, as well as promote evolving programs that introduce a new level of practice and comprehensive airway safety engagement.

Finally, this Airway Safety APPS serves as a launching point calling for a multi-disciplinary Global Airway Safety (GAS) Collaborative to support further development, assessment, implementation, and promotion of clear actionable solutions for strengthening airway safety awareness, education, management, research and policy.

Threats and Vulnerability

Delayed, missed or lost airways can result in death or catastrophic injuries that are almost always preventable. In particular, endotracheal intubation via direct laryngoscopy is a skill intensive, physically challenging, single operator technique, which has an unacceptable rate of failure, even in the hands of airway specialists. Unrecognized esophageal intubation, multiple failed attempts at securing the airway, aspiration of gastric contents, airway injury, dental trauma, hypoxemia and brain injury are tragically all too common.

The wide variation of techniques and technology for airway management is a key contributing factor to patient outcomes. Although the goals of airway management are essentially uniform, clinical approaches depend heavily on provider specialty and physical locale in healthcare settings, without standardization of best practices. For example, video laryngoscopy (VL) equipment is not reliably available in all areas, despite a wealth of scientific evidence that demonstrate its clinical superiority over direct laryngoscopy in a variety of clinical settings. The incidence of failed airways can be as high as 1 in 50 in the ED and ICU settings and the occurrence of death or brain damage have been reported to be 38 fold (ED) to 58 fold (ICU) higher than in OR settings \cite{Cook_2012}. Adverse events from airway management failure may be even higher in non ED/ICU hospital settings. Incidences of inadvertent airway extubation are also serious threats that can lead to death or severe disability.

Missed airways in the EMS setting have been reported to be as high as 52% \cite{Hubble_2010}. Although airway management can be successfully performed by paramedics in the field (success rates as high as 97.7%), variations in training, techniques, and technology result in many systems with less than optimal provider competence and inadequate intubation success rates (47.6%). The approach to airway management in the EMS setting has undergone a dramatic transformation since the advent of video laryngoscopy \cite{Chemsian_2014}. Video laryngoscopy improves laryngeal view and results in high rates of endotracheal intubation (ETI) success, both during first pass attempts and after difficult or failed direct laryngoscopy in the hospital setting \cite{Silverberg_2015,Aziz_2011}. However, due to the high cost of video laryngoscope equipment, EMS has not widely adopted VL and therefore the ETI success rates in the field remain low.

Studies indicate that unrecognized esophageal intubation in prehospital settings is as high as 25% \cite{Katz_2001}. With the outcome of an unrecognized esophageal intubation frequently being death, and with the availability of capnography which allows for easy recognition of malpositioned placement of the endotracheal tube, any unrecognized episode of esophageal intubation is avoidable. Yet some EMS agencies have not adopted waveform capnography and unrecognized esophageal intubations still occur.

Unplanned extubation, both in the field and in the hospital, is an avoidable, costly problem. Unplanned extubation occurs in over 7% of patients undergoing mechanical ventilation in the Intensive Care Unit and the complications of unplanned extubations result in over $4 Billion in healthcare costs \cite{da_Silva_2012}. Although the incidence is likely higher in EMS settings due to the difficulties of transporting critically ill patients in a chaotic environment, unplanned extubation is not tracked in most EMS data systems. Similarly, most hospitals do not track unplanned extubations and therefore the 7% incidence may be an underestimate.

Because of underreporting, the true incidence of airway management related injuries is unknown. What is clear, however, is that the healthcare industry must transition away from viewing airway management related injuries as the inevitable “cost of doing business” and redefine these complications as preventable iatrogenic harm.

Gaps

The overwhelming majority of hospitals currently lack standardization of airway management among individual providers, teams, units or institutions. In addition, they have significant vulnerabilities due to inadequate or absent essential safety components such as:

Leadership Plan

Models currently exist for comprehensive airway safety improvement with high leverage interventions. The Veteran’s Health Administration (VHA) recently initiated the Out of OR Airway Management (OOORAM) directive and the multidisciplinary Safer Airway Program is currently under development.

The Safer Airway Program is a comprehensive, team-based system solution that hardwires evidence-based best practices in clinical settings and safety science. It provides broad recommendations and customizable tools for multiple healthcare settings including emergency departments, intensive care units and general medical/surgical units, procedural areas and calls for implementation of proven solutions such as Failed Airway Protocols (FAP), comprehensive equipment cart/systems, essential clinical practices, checklist utilization and team training.

Executive Summary ChecklistAn effective program to reduce the incidence of pediatric adverse drug events (pADEs) and harm should be instituted and combine leadership strategies, software (healthcare IT), hardware (drug compounding systems, drug delivery technology, and physiological monitoring systems), and most importantly people (changes in clinical practice, protocols and education) in protecting pediatric patients by focusing on the following key tasks:Demonstrate board and executive leadership engagement and commitment by aligning hospital-wide strategic goals, accountability and systems to reduce pADEs.Create a multidisciplinary team specialized in neonatal and pediatric medicine that reports regularly to executive leadership, with a focus on pADE.Institute an effective software program for identifying, detecting, and reporting pADEs with analysis of the incidence and characteristics of pADEs and the near-misses.Deploy a closed loop medication administration system by implementing an electronic medication administration record (eMAR) and barcoding, or other auto identification technology with computerized provider order entry (CPOE) and pharmacy for medication administration.Institute proven interventional bundles for pADEs:Standardized order sets and protocols for each admitting diagnosis;CPOE with sophisticated decision support systems (DSS) including medication reconciliation, allergy checking, interaction checking, and dose range checking with alerts;Enhanced pharmacy services including clinical pharmacists on rounds, implementing a double-check process as part of medication verification prior to dispensing high-risk medications, utilizing improved IV compounding tools such as bar code assisted medication preparation system (BCMP), and improving workforce skills to assure correct drug compounding and a pharmacy intervention database;Ensure open communication and standardized medication handoff processes between healthcare teams at shift changes to verify medications are being administered correctly compared to the order, and that patient monitoring parameters for high alert medications are in place;‘Smart’ drug infusion pumps with drug libraries that are harmonized with order sets and enterprise formularies that include pediatric standardized drug concentrations addressing all weight ranges and are periodically updated based on review of an incident database, alert and override data;Support tools to ensure that the correct concentration of drug in diluent is prepared, taking into account fluid balance for small patients and patients with fluid restrictions, and an infusion rate that is acceptable and within pump capabilities in all areas where children receive care.Select and implement new enterprise clinical information systems and electronic health records, verify and assess that the features of an organization’s healthcare IT system includes full support for best practices in age- and weight-specific prescribing, compounding, dispensing, and administration of pediatric medications.Consider relevant improvement initiatives and opportunities for collaboration in pADE reduction outside of the hospital system.Disseminate pediatric-specific assistive technologies such as eBroselow (or equivalent) to assure that basic capabilities to stabilize and treat acutely ill or injured children are present 24/7 throughout all environments of care.Ensure that the FDA Safety Communication: “Syringe Pump Problems with Fluid Flow Continuity at Low Infusion Rates Can Result in Serious Clinical Consequences” is reviewed and understood by the team. [MG Consider use of a different standardized solution if patient weight and dose volume are beyond the pump's capability]Utilize Continuous Quality Improvement (CQI) software from infusion pump manufacturers to monitor drug library parameters on a routine basis and to report the frequency of command overrides and alerts triggered for unsafe practices.The Performance GapAs reported by the Institute for Safe Medication Practices (ISMP), during a 5-year span between 2008 and 2012, there were over 45,000 adverse drug events (ADEs) reported to the US Food and Drug Administration (FDA) in children aged less than 18 years old. Of these, approximately 64% of ADEs (29,298) involved reports of a serious injury, which included 2,935 (6%) deaths, 10,032 (22%) cases that required hospitalization, 1,430 (3%) cases considered life threatening, and 816 (2%) cases of disability \cite{5}(Quarter Watch 2014).Preventing medication errors in pediatric patients poses unique challenges as children are particularly vulnerable to adverse outcomes from medication errors because of the need for weight-based drug dosing involving multiple calculations, dilution of stock drug solutions, immature renal and hepatic functions, and limited ability to communicate side effects \cite{Kaushal_2001},\cite{2011},\cite{23055866}. In addition, drugs may be not have an FDA specific indicationfor children. Greater than 70% of the drugs used in pediatrics have not been studied scientifically in age-specific populations to assess patient safety \cite{23055866},\cite{Lindell_Osuagwu_2009}. Most medications used in the care of children are formulated and packaged primarily for adults. The available dosage forms and concentrations appropriate for administration to neonates, infants and children are limited. Therefore, medications often must be prepared in different volumes or concentrations to accommodate delivery modalities that take into account fluid balance for small patients andpatients with fluid restriction, and, if an infusion pump is required, provide an infusion rate that is acceptable and within pump capabilities. When drugs are not prepared centrally in the pharmacy (i.e., extemporaneous compounding by frontline caregivers), computational errors and admixtures that do not account stability, compatibility, or bioavailability data may represent additional challenges \cite{6}.Studies showed that medication errors in pediatrics are up to three times more likely to be associated with a potential ADE compared to those reported in adults (Kaushal 2001),\cite{Fortescue_2003}. Compared to other pediatric patient groups, the neonatal ICU patient group has the highest error and potential ADE rate. Prioritizing strategies for preventing medication errors and adversedrug events in pediatric inpatients \cite{Kaushal_2001},\cite{Le_2006}. As reported in an earlier study, ADE rates in hospitalized children were substantially higher (15.7 per 1000 patient-days) than previously described \cite{Takata_2008}. However, 22% of all ADEs could be preventable, and 17.8% could have been identified earlier \cite{Takata_2008}.In 2001, the ISMP and the Pediatric Pharmacy Advocacy Group (PPAG) collaborated to produce the nation’s first set of guidelines to reduce pediatric medication errors \cite{7}. The American Academy of Pediatrics (AAP) has also taken a lead in making recommendations to reduce errors \cite{2003}.Closure of performance gaps and “getting to zero” medication errors will require the constant vigilance from all healthcare professionals and the commitment of hospitals and healthcare systems to implement action in the form of specific leadership, practice and technology plans. This will lead to a decrease in medication errors and a reduction in the occurrence of preventable ADEs in pediatric patients.Leadership PlanThe hospital board, executives and other senior administrative leadership (medicine, pharmacy and nursing) must fully understand the performance gaps in reducing pADEs at their own healthcare systems. Commitment from all the leaders and stakeholders is necessary for the successful closure of these performance gaps. Leaders should endorse a comprehensive pADE reduction action plan and ensure implementation across all providers and systems. Strategic and tactical approaches that hospital leadership should endorse include the following:Establish pADE reduction as a strategic priority by creating a clear metric and goal that are included on the hospital-wide dashboard reviewed by the board and senior executives.Invest and allocate funds to:Develop and maintain continuous education programs for healthcare providers with respect to pediatric clinical updates, high alert medications, pADEs monitoring and proper use of drug infusion pumps \cite{Manias_2014},\cite{Cimino_2004},\cite{Keiffer_2015},\cite{11148939},\cite{Wolf_2016}.Develop and maintain continuous education programs for healthcare providers with respect to pediatric clinical updates, high alert medications, pADEs monitoring and proper use of drug infusion pumps. (Manias, Cimino, Keiffer, Stump, Wolf)Support clinical and research programs to develop an educational forum and “Best Practices”model for healthcare providers to expand the body of knowledge in pediatric medicine.Encourage and support the use of a simple, real-time pADE reporting system \cite{Stump2000}.Review accurate, up-to-date pADE data at least monthly \cite{Stump2000}.Encourage and support the use of a simple, real-time pADE reporting system \cite{11148939}.Review accurate, up-to-date pADE data at least monthly \cite{11148939}.Charter a committee or task force to review the reported data at the hospital and unit levels, generate and implement strategies for improvement, analyze barriers and regularly report to executive leadership \cite{11148939}.Expect a comprehensive root cause analysis of all pADEs that involve serious patient harm. The analysis should include the root cause of the medication error, feedback to the individual linked to the error, implementation of time-bound and evidence-based changes to avoid similar pADEs, and widespread sharing of lessons learned \cite{11148939}.Charter a committee or task force to review the reported data at the hospital and unit levels, generate and implement strategies for improvement, analyze barriers and regularly report to executive leadership \cite{Stump2000}.Expect a comprehensive root cause analysis of all pADEs that involve serious patient harm. The analysis should include the root cause of the medication error, feedback to the individual linked to the error, implementation of time-bound and evidence-based changes to avoid similar pADEs, and widespread sharing of lessons learned \cite{Stump2000}.Support the development of a lessons learned program to raise awareness among providers across the spectrum of medication delivery about pADE events, risks and improvement efforts using longitudinal data, individual events and near misses.Assess staffing and ensure an adequate number of medical, nursing and pharmacy staff specially trained to prescribe, prepare, dispense, and administer medications to children (Stucky, Wolf).Promote and enhance collaborative communication among all disciplines participating in neonatal and pediatric patient care, including pharmacy staff, patients and families (Fortescue 2003).Assess staffing and ensure an adequate number of medical, nursing and pharmacy staff specially trained to prescribe, prepare, dispense, and administer medications to children \cite{2003},\cite{15511054}.Promote and enhance collaborative communication among all disciplines participating in neonatal and pediatric patient care, including pharmacy staff, patients and families \cite{Fortescue_2003}.Consider relevant improvement initiatives and opportunities for collaboration in pADE reduction outside of the pediatric hospital system such as ECLIPSE, \cite{Blandford_2016} FDA-ASHP Standardize for Safety (S4S) Initiatives and OCHSPS.Implement and disseminate assistive technologies that support community practitioners as they stabilize, treat and transfer neonates and children in higher levels of care.Practice PlanStandardize pediatric medication treatments and usage, as well as the processes for drug administration in pediatric patients. Some strategies include the following:Establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use \cite{6},\cite{2003}.Develop and optimize a smart infusion pump drug library with explicit support for intravenous therapy for pediatric patients \cite{Manrique_Rodr_guez_2012},\cite{Manrique_Rodr_guez_2012a}.Prevent timing errors in medication administration by standardizing the number of days considered in all pediatric protocols upon deciding a treatment start date (e.g., Day 0 or Day 1) \cite{6}.Weigh all pediatric patients in kilograms at the time of admission or as soon as possible (i.e., within four hours of admission) in an emergency situation since weight is used to calculate most dosing for children \cite{6}.Standardize and limit the number of concentrations and dosage strengths of high alert medications to the minimum needed to reduce potential medication errors \cite{6},\cite{19412363},\cite{Hilmas_2009},\cite{Murray_2014},\cite{15995017}. High alert medications for pediatric patients should be generated by individual hospitals based on their types of pediatric population, infrastructure and unique features \cite{Doherty_2012},\cite{Glanzmann_2015}.Establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use (Joint Commission 2008, Stucky).Develop and optimize a smart infusion pump drug library with explicit support for intravenous therapy for pediatric patients (Manrique-Rodriguez 2012).Prevent timing errors in medication administration by standardizing the number of days considered in all pediatric protocols upon deciding a treatment start date (e.g., Day 0 or Day 1)(Joint Commission 2008).Weigh all pediatric patients in kilograms at the time of admission or as soon as possible (i.e., within four hours of admission) in an emergency situation since weight is used to calculate most dosing for children (Joint Commission 2008).Standardize and limit the number of concentrations and dosage strengths of high alert medications to the minimum needed to reduce potential medication errors (Joint Commission 2008, Irwin 2008, Hilmans 2010, Murray 2014, Larson 2005). High alert medications for pediatric patients should be generated by individual hospitals based on their types of pediatric population, infrastructure and unique features (Doherty 2012, Glanzmann 2015).Develop age-related treatment algorithms to guide providers to the correct dosing appropriate for the age of the pediatric patient.Age- and weight-related developmental changes in pediatric patients affect the medication use process of specific drugs, and should be taken into consideration. The age-related treatment algorithms will be useful in preventing the use of medications outside the intended patient population.Use reputable, reliable references and protocols to help standardize pediatric medication therapies.Participate and track the progress of the FDA-ASHP Standardize for Safety Initiative.Evaluate clinical guidelines and protocols on a routine basis for sustainability and safety, especially when limited safety and/or efficacy data are available in the pediatric population.Develop and implement a pediatric trigger toolkit that will electronically identify high risk medications based on the therapeutic levels, dosages and pADEs.Alignment of the trigger toolkit with clinical protocols specific for the medication.Utilization of an ADE trigger tool method to identify possible adverse events have been shown to ensure more patient safety events compared to voluntary reporting \cite{22479163},\cite{Call_2014}.The pediatric trigger toolkit is effective at identifying ADEs and reducing the frequency of sentinel events for hospitalized pediatric populations \cite{Takata_2008}.Create a pediatric multidisciplinary team. This team’s responsibilities will include the following:Achieve hospital-wide pADE reduction goals;Monitor accurate, up-to-date pADE metrics;Collaborate in a multidisciplinary team (e.g., physicians, pharmacists and nurses) to promote and endorse accountability and responsibility in reporting pADEs from all healthcare providers \cite{22768013},\cite{Stratton_2004}.For example, a pharmacy-driven ADE reporting approach, embraced by nurses and physicians, was shown to improve ADE reporting and avoid inconsistency in the information gathered.Develop and ensure comprehensive specialty training for all practitioners involved in the care of pediatric patients, as well as continuous education programs for healthcare providers to stay current and knowledgeable in medications and treatment of pediatric conditions, and be familiar with the ongoing pADE tracking and reporting systems \cite{6},\cite{2003}.Collaborate with the Informatics Technology team to develop and customize CPOE order sets to help standardize care and medication therapy for specific pediatric disease states \cite{Potts_2003}.Develop a team of experts (e.g., physician, pharmacist and nurse) to train healthcare providers at their hospital on how to use the smart infusion pumps with customized pediatric drug libraries \cite{Manrique_Rodr_guez_2012a}.Develop and standardize a smooth and effective communication process for hand-offs (e.g. using a checklist)\cite{26390744},\cite{Halasyamani_2006} upon patient transfer to a different unit within the hospital, and upon the transitions of care within and outside clinical settings \cite{25209739},\cite{Manias_2009},\cite{Apker_2007}.Ensure adequate pharmacy services for pediatric patients to reduce medication errors and ADEs \cite{Manias_2014}. The strategies proposed by the American College of Clinical Pharmacy (ACCP) and PPAG include:\cite{Bhatt_Mehta_2013}Develop and implement pharmacist-managed admission medication histories and medication reconciliation process for pediatric patients, which have shown to prevent potentially significant adverse drug reactions and have a positive impact on patient care \cite{Provine_2014}.Develop and implement a discharge prescription review program, led by a clinical pharmacist (with pediatric training preferred), to ensure the medication doses are equivalent to those prepared in the hospital. This is an effective method for reducing prescribing errors in pediatric patients during transition of care \cite{23055881}.Achieve hospital-wide pADE reduction goals; ○Monitor accurate, up-to-date pADE metrics;Ensure outstanding event reporting systems, root cause analyses, lessons learned processes and improvement strategies for pADE reduction;Develop an education forum for community healthcare providers (e.g., physicians, pharmacists and nurses) about appropriate prescribing and dispensing medications for pediatric patients \cite{22768015}.Disseminate pediatric-specific assistive technologies such as eBroselow (or equivalent) to assure that basic capabilities to stabilize and treat acutely ill or injured children are present 24/7 throughout all environments of care \cite{25309147}.Benchmark the adequacy of the features of the individual hospital’s medication safety practices and clinical information systems against the proven best practices, identify gaps, and make recommendations.Collaborate in a multidisciplinary team (e.g., physicians, pharmacists and nurses) to promote and endorse accountability and responsibility in reporting pADEs from all healthcare providers (Crowther 2011, Stratton 2004).For example, a pharmacy-driven ADE reporting approach, embraced by nurses and physicians, was shown to improve ADE reporting and avoid inconsistency in the information gathered (Crowther 2011).Develop and ensure comprehensive specialty training for all practitioners involved in the care of pediatric patients, as well as continuous education programs for healthcare providers to stay current and knowledgeable in medications and treatment of pediatric conditions, and be familiar with the ongoing pADE tracking and reporting systems (Joint Commission 2008, Stucky 2003).Collaborate with the Informatics Technology team to develop and customize CPOE order sets to help standardize care and medication therapy for specific pediatric disease states (Potts 2004).Develop a team of experts (e.g., physician, pharmacist and nurse) to train healthcare providers at their hospital on how to use the smart infusion pumps with customized pediatric drug libraries (Manrique-Rodriguez 2012).Develop and standardize a smooth and effective communication process for hand-offs (e.g. using a checklist)32,33 upon patient transfer to a different unit within the hospital, and upon the transitions of care within and outside clinical settings (Manias 2015, Manias 2009, Apker 2007).Ensure adequate pharmacy services for pediatric patients to reduce medication errors and ADEs.12The strategies proposed by the American College of Clinical Pharmacy (ACCP) and PPAG include: (Bhatt-Mallak 2007)Elevating the minimum expectations for pharmacists entering pediatric practice,Standardizing pediatric pharmacy education,Expanding the current number of pediatric clinical pharmacists,And creating an infrastructure for development of pediatric clinical pharmacists and clinical scientists.Develop and implement pharmacist-managed admission medication histories and medication reconciliation process for pediatric patients, which have shown to prevent potentially significant adverse drug reactions and have a positive impact on patient care (Provine 2014).Develop and implement a discharge prescription review program, led by a clinical pharmacist (with pediatric training preferred), to ensure the medication doses are equivalent to those prepared in the hospital. This is an effective method for reducing prescribing errors in pediatric patients during transition of care (Christiansen 2008).Implement pharmacist-driven processes, such as developing a double- and triple-check system for high alert medications to ensure the “5 Rights”, appropriate medication selection, and accurate excipients, dose and concentrations of liquid medications prior to compounding and dispensing them.Develop an education forum for community healthcare providers (e.g., physicians, pharmacists and nurses) about appropriate prescribing and dispensing medications for pediatric patients (Benavides 2011).Disseminate pediatric-specific assistive technologies such as eBroselow (or equivalent) to assure that basic capabilities to stabilize and treat acutely ill or injured children are present 24/7 throughout all environments of care (Damhoff 2014).Technology PlanSuggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.Technology has significantly advanced in the last decade within the healthcare setting with development of Electronic Health Records (EHR), CPOE, barcode medication administration (BCMA), bar code assisted medication preparation system (BCMP) and smart pump infusion technology. Multiple studies in pediatrics have demonstrated a decrease in both prescribing errors and ADEs after implementing these technologies (Manias 2014, Larsen 2005, Morriss 2009, Tourel 2012, Mason 2014, Morriss 2011, Hardmeier 2014, King 2003, Leung 2015, Manrique-Rodriguez 2016, Rinke 2014). However, most of these systems are designed for use in adult patients and customization is often needed to ensure optimal use in pediatric patients (Ruano 2016).Work with the multidisciplinary healthcare team to develop, improve and optimize the pADE reporting systems to identify, target, track and monitor pADEs.Embed a pediatric trigger toolkit in the CPOE as an alert system for prescribers when medications are ordered out of range or are duplicate therapies (Takata 2008, Burch 2011, Call 2014).Develop and optimize real-time surveillance systems to identify high risk/high alert medications and to optimize pediatric patient outcomes via mitigation of pADEs.Standardize equipment and measurement systems throughout the institution, such as smart infusion pumps and accurate weight scales for pediatric patients (Stucky 2003).Ensure best practices are used for syringe pumps with medications requiring low infusion rates (<5 mL per hour) to prevent medication errors (FDA Safety Communication 2016, Sherwin 2014).Ensure that the FDA Safety Communication: “Syringe Pump Problems with Fluid Flow Continuity at Low Infusion Rates Can Result in Serious Clinical Consequences” is reviewed and understood by pharmacists who dispense drugs for use in programmable syringe pumps, by clinical engineers and technicians who maintain programmable syringe pumps, and by caregivers who use or who train users on programmable syringe pumps (FDA Safety Communication 2016).Promote eLearning modules on this topic, (Massachusetts General Hospital Anesthesia) prepared by Massachusetts General Hospital, are freely available at syringeinfusionsafety.org as referenced by the FDA in the Safety Communication.Implement and optimize bar coded medication process for pediatric medication products (e.g., multi-dose or unit-dose vials, compounded, and/or repackaged).(ASHP Foundation)Use a bar code assisted medication preparation system (BCMP) for intravenous sterile compounding in pharmacy, such as Baxter’s DoseEdge Pharmacy Workflow Manager, BD’s Cato™ Medication Workflow Solutions, and Omnicell’s i.v.SOFT® Assist.Use the eBroselow System (or equivalent) as an electronic aid to assist those who compound drugs extemporaneously, in achieving compliance with standardized concentrations that respect fluid balance considerations for small patients and patients with fluid restriction, and are compatible with the performance envelope of drug infusion pumps (Damhoff 2014).Use the Codonics Safe Label System,56 or the BD Intelliport Medication Management System, to assure correct source vial identification, container preparation, and Joint Commission- compliant labeling of drugs given by IV push or infusion in the perioperative environment (Nanji 2016).Utilize Continuous Quality Improvement (CQI) software from infusion pump manufacturers to monitor drug library parameters on a routine basis and to report the frequency of command overrides and alerts triggered for unsafe practices (Ohashi 2013, Bergon-Sendin 2015).Analyze and proactively respond to identified issues from smart pump data to minimize use of basic mode.Develop systems to perform gap and root cause analyses to improve patient and medication safety.With technology prevalent in healthcare, physicians, pharmacists and nurses should use both synchronous and asynchronous forms of communication to improve medication safety at the transitional points of care (Manias 2009).Develop and optimize communication technology across healthcare settings, providers and caregivers of the pediatric patients via secured HIPAA-protected lines (e.g., telemedicine and apps).

Executive Summary Checklist

In order to establish a program to eliminate Venous Thromboembolism (VTE), an implementation plan with the following actionable steps is recommended as best practice science to reduce patient harm. The following core action items and prevention strategies are outlined below using an interdisciplinary, best practice approach:

Hospital governance and senior administrative leadership must champion efforts in raising awareness around the high incidence of VTEs and prevention strategy measures.

Healthcare leadership should support the design and implementation of standards and provider training programs on VTE reduction and prevention strategies by:

Complete in depth chart review for hospital-associated thrombosis events to identify opportunities for improvement and then acting on lessons learned

Adhere to VTE best practices from national organizations such as Agency for Healthcare Research and Quality’s VTE Safety Toolkit.\cite{AHRQVTE1} The toolkit contains 10 components that are evidence-based guidelines for preventing, diagnosing, treating, and educating patients and providers about VTE. The components are as follows:

Executive Summary Checklist

Complications arising from hypertensive disorders of pregnancy are among the leading causes of severe maternal morbidity and preventable maternal mortality. This maternity patient safety topic was selected by the National Partnership for Maternal Safety for priority development and national implementation. This safety bundle outlines critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care. The hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources to assist with implementation \cite{pe1}.